ORIGINAL RESEARCH
Section: Obestrics and Gynaecology
Ruptured Ectopic Pregnancy, the Challenges for the Obstetrician:
Single Center Prospective Study
Kaveri Shaw Patel1, Roma Sonkar Nag2, Lovely Jain3
ABSTRACT
Introduction: Ruptured ectopic pregnancy is a life threatening
obstetrical emergency and presents in various ways. The
aim was to evaluate predisposing factors associated with
development of ectopic pregnancy in current scenario and
evaluation done for association between ectopic pregnancy
and constellation of signs/ symptoms.
Material and Methods: A prospective study conducted
between Jan 2017 to April 2018 at a tertiary center for women
attending emergency department presenting to our center with
complains of missed period or scanty periods with abdomen
pain were included. Women with abdominal pain and non
suspicious of ectopic pregnancy and medically planned cases
of ectopic pregnancy were excluded.
Results: The prevalence of ruptured ectopic pregnancy in
present study was 1.84% amongst all antenatal cases entering
to the hospital. The predominant complain was abdominal
pain(95.45%), missed periods (77.27%) and vomiting (50%).
The positive past history of use of emergency pill (36.36%)
and unsupervised medical abortion pill (27.27%), tubal
surgery (22.73%) and PID (50%) were associated factors.
The serum βhCG was significantly associated in rupture EP.
The abdominal tenderness and hemoperitonuem was found
strongly associated. The morbidity assessed by high blood
transfusion rate (86.36%).The commonest site of rupture was
ampulla 68.18% of fallopian tube.
Conclusion: The ruptured ectopic pregnancy is a life
threatening emergency obstetrical condition a. The
unsupervised usage of abortificient along with atypical
clinical history have increased diagnostic dilemma in ectopic
pregnancy therefore Early diagnosis and treatment of ectopic
pregnancy are the only modality available to prevent tubal
ruptured and its associated morbidity.
Keywords: Ampulla, βhCG, Ectopic Pregnancy, Medical
Abortificient Trans Vaginal Ultrasonography, Emergency Pill,
LNG Pill, PID, Shock, Salpingectomy, Hemoperitonuem,
Laparotomy
INTRODUCTION
An ectopic pregnancy occurs when a fertilized ovum implants
outside the normal uterine cavity.1,2 The incidence of ectopic
pregnancy in the general population is about 2%.3 It is a
common cause of morbidity and occasionally of mortality
in women of reproductive age. A prospective case-controlled
study has shown that increased awareness of ectopic
pregnancy and a knowledge of the associated risk factors
helps identify women at higher risk in order to facilitate
early and more accurate diagnosis.4 Despite the relatively
high frequency of this serious condition, early detection
can be challenging. In up to half of all women with ectopic
International Journal of Contemporary Medical Research
ISSN (Online): 2393-915X; (Print): 2454-7379 | ICV: 77.83 | Volume 5 | Issue 5 | May 2018
www.ijcmr.com
pregnancy presenting to an emergency department, the
condition is not identified at the initial medical assessment.5
In view of challenging diagnosis the aim of the current study
is to evaluate the various risk factors associated in the cases
of ruptured ectopic and to study the association of factors
amongst them.
MATERIAL AND METHODS
A prospective study conducted for the period of Jan 2017 to
April 2018 at tertiary care center for the women attending
emergency department.
The women presenting to our center with complains of
missed period or scanty periods with abdomen pain were
included.
The exclusion criteria were all women with diagnosis of
lower abdominal pain but non suspicious of EP and medically
planned cases of EP.
The detail history, clinical findings, Ultrasonography
findings, intra operative findings and post operative recovery
details for all study population taken and entered in excel
sheet.
There were 1180 overall new pregnancy with missed periods
with pain in abdomen and 723 acute abdomen(pregnancy/
missed period, not sure) cases registered to the center.
Among all only those who were fitting into the inclusion
criteria, underwent laparotomy and diagnosed intra operative
as ruptured ectopic taken for the study.A total of 22 cases
diagnosed with rupture ectopic .
All data was collected in Microsoft excel sheet. All the data
is expressed in mean ± standard deviation. Distribution is
expressed as a percentage of total number in population
in actual numbers. The categorical distribution calculated
by chi square test . The statistical analysis was done using
statistical package for social sciences (SPSS) Version 17.0
IBM Computers New York and Excel.
1
Consultant, Gynae-Oncosurgery, Shalby Hospital, 2Consultant,
Shalby Hospital, 3Senior Resident, Department of Anatomy, NSCB
Medical College, Jabalpur, India
Corresponding author: Dr Lovely Jain, Flat No. 407, Shambhu
Shree Apartment, Ekta Chowk, Vijaynagar, Jabalpur, MP, PIN
482001, India
How to cite this article: Kaveri Shaw Patel, Roma Sonkar Nag,
Lovely Jain. Ruptured ectopic pregnancy, the challenges for the
obstetrician: single center prospective study. International Journal
of Contemporary Medical Research 2018;5(5):E1-E5.
DOI: http://dx.doi.org/10.21276/ijcmr.2018.5.5.20
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 Patel, et al. Rupture Ectopic Pregnancy, the Various Predictors and Association
Section: Obestrics and Gynaecology

RESULTS Bondada Present

There were 22 patients enrolled in the study who were et al study
Unilateral salpingectomy 53.30% 86.36%
fulfilling the criteria for the duration of Jan 2017 to Apr 2018.
Salpingo-oophorectomy 11.10% 9.09%
The incidence of the disease was 1.84% (22/1180) of overall
Unilateral salpingectomy with contra- 15.50%
pregnancy enrolled and 3.04% (22/723) of overall cases of lateral tubectomy
acute abdomen attended the emergency department.(table 1) Segmentectomy with recanalization - 4.55%
Segmentectomy 4.55%
Demographic factors Numbers % Table-8: Type of Surgical Procedures Performed
primigravida 7/22 31.82
multipara 15/22 68.18 120
H/O previous EP 3/22 13.63
IVF 1/22 4.55 100
95.45
Table-1: Distribution of associated demographic factors
80 77.27

Age group distribution Numbers % 60

54.55
<20 yrs 0 0 50 45.45
40
20-25 yrs 6 27.27
26-30 yrs 7 31.82 20 22.7
31-35 yrs 8 36.36
0
>35 yrs 0 0 vomiting giddiness Lower Shock Missed Spotting
Table-2: Age wise distribution of the cases abd period
pain
Figure-1: Distribution of clinical presentation
Variables Number %
MA 6 27.27%
Use of emergency contraceptive pills 8 36.36%
(LNG)
previous tubal surgery 5 22.73%
PID 11 50.00%
No risk factor 3 13.64%
Table-3: The associated risk factor distribution

Correlation in GA and 5 week <6 week

β-hCG
<1500 13 (10.91) [0.4] 2 (4.09) [1.07]
>1500 3 (5.09) [0.86] 4 (1.91) [2.29]
Table-4: Correlation in GA and β-hCG

Hemoperitonuem Cases Percent

Legend-1: Intraoperative photograph of Ruptured Ampulla of
1000 ML or less 8 36.36%
fallopian tube; Legend-2: specimen of ruptured ovarian ectopic
101-500ML 11 50%
pregnancy
<100ML 3 13.63%
Table-5: TVS finding of hemoperitoeum The majority of ruptured EP (68.18%) were multiparous. The
commonest age group presented with ruptured EP was 31-35
Procedure No. cases Percentage year (36.36%) (table2). In 95.45% of cases the presentation
Salpingectomy± oophorectomy 19 86.36% was pain in lower abdomen and 45.5% of cases were
segmentectomy 2 9.09% received in condition of shock. Vomiting was associated in
segmentectomy with recanalization 1 4.55% 50% of cases; giddiness was there in 54.55% amenorrhea
Table-6: Procedures on ruptured EP 77.27%and in 45.55% of cases bleeding per vaginum was
present (figure 1).
Rashmi A Rose et Bondada Present The etiological /risk factors associated in the present
Gaddagi al. (2002) et al study population were PID in half of the cases. The second most
et al common associated factor (36.36%) was the use of emergency
Ampulla 70.3% 83.9% 40% 68.18% contraception pill containing Levonorgestrol. In 13.64% no
Isthmus 3.0% 39.78% 22.20% 27.27% risk factor was found. The other factors were use of medical
Ovarian - 1.07% 4.40% 4.54% abortificient 27.27% and history of tubal surgery 22.73%
Table-7: Comparison of the anatomical site of the ectopic and history of d&c 18.18% while in 36.36% of cases there
pregnancies were multiple risk factors involved (Table-3). The urinary

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Volume 5 | Issue 5 | May 2018 | ICV: 77.83 | ISSN (Online): 2393-915X; (Print): 2454-7379
Patel, et al. Rupture Ectopic Pregnancy, the Various Predictors and Association
pregnancy test was found positive in 90.9% (20/22) cases
while culdocentesis was positive only in 31.8% (7/22) of the
cases. On per abdominal examination unilateral tenderness
was more frequently encountered (68.18%), while on per
vaginal examination Tenderness on cervical movement was
present in 31.81% of the cases and masses in the fornices
were present in 50% of the cases.
Severe anemia was present in 50% cases on admission
and 81.81% required blood transfusion. The chi-square
statistic found a significant correlation (p <0.05) between
in Gestational age (GA) and β-hCG, The Higher the β-hCG
in early GA the more probability of rupture of EP (Table-4).
The significant hemoperitonuem 1 liter and more was seen in
36.36% ruptured ectopic cases. The majority of population
(50%) had blood loss of 100-500 ml on admission while
13.6% had less than 100 ml collection ultrasonographically
and intra operative. (TABLE-5). The chi square test for
association of hemoperitonuem and tenderness was found
significant (p<0.05).The results reflects that the more the
hemoperitoneum higher the tenderness in abdomen and
cervical motion. The intra op laparotomy finding were
suggestive of ruptured tubal ectopic in 90.9% cases while
tubal abortion in 2 cases
The majority of ectopic site was Right side tubal ectopic
(50%) with ampulla in 68.18% (15/22) cases. In laparotomy
the most common procedure carried out was salpingectomy±
oophorectomy 86.36%, only segmentectomy 9.09% and
segmentectomy with recanalization in single case (Table-6).
Almost 86.36% cases required blood transfusion of 2 to 3
unit.
DISCUSSION
In various studies ectopic pregnancy rates range from 0.8%
to 2% of all reported pregnancies; in our study the rate of
ectopic is 1.84% (overall antenatal booked) to 3.04% (overall
acute abdomen) comparable to previous studies.6,7
Clinical symptoms
The presentation of extra uterine pregnancy is highly
variable, ranging from an asymptomatic state, to pelvic pain
that is worse on one side, to tubal ruptured with hemorrhagic
shock.8
There were 95.45% presented with complain of lower
abdomen pain, 45.5% were received in shock and the rest
had complain of vomiting (50%), giddiness (54.55%)
and bleeding per vaginum (45.55%). The most common
presenting symptom was abdominal pain in 37 (97.3%)
patients whereas history of amenorrhea and vaginal
bleeding were found in 28 (73.6%) and 22 (57.8%) patients
respectively comparable to present study.9
Risk factors
The risk factors associated in ruptured EP are numerous
enlisted but predominantly few have been evaluated
repeatedly in few studies like parity, previous history of
ruptured EP, use of LNG pill, PID etc.
PID and Ectopic Pregnancy in number of studies is Rashmi
et al 8.1%, In March Banks’ study (1998) - 4% In Savitha
International Journal of Contemporary Medical Research
ISSN (Online): 2393-915X; (Print): 2454-7379 | ICV: 77.83 | Volume 5 | Issue 5 | May 2018
Section: Obestrics and Gynaecology
Devi’s study (2000) - 25% In Rose et al., study (2002) -
34.4% The etiological /risk factors associated in the present
population were PID in half (50%)of the cases.10
Previous history of ectopic pregnancy and parity seem
to be significant risk factors for ruptured of an ectopic
pregnancy according to Michael Sindos et al study.11 While
the probability of another ectopic pregnancy decreased as the
parity increased (70%) in observational study by Sobande
AA12, in observational study by Sobande AA and etal 74%
multipara developed ruptured EP.11,13
Our results indicate that use of emergency contraceptive pills,
in the two forms widely available today, does not increase
the risk that a pregnancy after treatment will be ectopic. Use
of LNG –EC (levonorgesterol emergency contraception) has
been found associated with risk of developing EP incidences
ranging from 2.3% -4.1%.14,15 There has been number of
studies which elaborate the reason of failure of EC due to
improper use of EC by user, followed by regular Intercourse,
multiple time intake of LNG-EC in the same cycle.16 In the
present cohort the use of LNG –EC was seen in 36.36%
cases of ruptured EP. This also reflects that more of the EC
user population is being served by the present center.
Another interesting fact is use of medical abortion pills and
the relation of EP. The literature suggests that a very low
frequency of ectopic pregnancies diagnosed after medical
abortion treatment demonstrates that the various pretreatment
screening methods that providers use to exclude patients
with ectopic pregnancies are successful.17 Further, there is no
evidence to suggest that medical abortion treatment leads to
unusual complications for women with ectopic pregnancies.
The fact is, these all data include those participants who are
using medical abortion under supervision. These studies are
done on medical records. The self medication of abortificient
without supervision increases the chances of missing the EP.
The overall risk of developing EP by OTC abortificient is as
high up to 1.9% to 6.5%.18,19
Clinical and biochemical markers
The clinical examination in case of acute abdomen gives a
better idea when associated with biochemical markers. The
most common physical sign was tenderness: abdominal
tenderness in 15 (68.18%) and pelvic tenderness in
7(31.18%) patients. The values in previous studies reflected
that abdominal tenderness is more (73.6% and 77.7%)
and sensitive marker, Shah N et al and Jophy R et al
respectively.9,20 which was seen in our study too. Per vaginal
tenderness was seen in previous studies more as compare to
present study.
The correlation between abdominal (64±9.14) and per vaginal
tenderness (36±2.77) with TVS collection more than 500 (25
±2.08) and less than 500 (49±4.08) reflected that more the
collection more the tenderness which is a significant marker
in assessment of diagnosis(.p<0.01). This is consistent with
previous studies like Shalev and colleagues found that the
use of TVS in the diagnosis of an ectopic pregnancy has a
sensitivity of 87%, specificity of 94% and positive predictive
value of 92.5%.21 The Trans vaginal ultra sonography (TVS)
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 Patel, et al. Rupture Ectopic Pregnancy, the Various Predictors and Association
Section: Obestrics and Gynaecology
is sensitive marker in the diagnosis of ruptured EP and
another marker is β-hCG.
Ectopic pregnancy is generally associated with a rise in
hCG by no more than 66%, or a fall by no more than 13%
from the baseline level, in 48 hours. A ratio lying within this
range, along with an absolute hCG value above 1500 IU/L
in the absence of any visualized intrauterine pregnancy, can
be taken as evidence for a probable ectopic pregnancy. This
combined criterion is 92% sensitive and 84% specific.22,23
Higher β-hCG levels seem to be significant risk factors for
ruptured of EP.24 In present study the significant p value
(<0.05) noted in the association of GA and β-hCG. The
data suggests that higher the value even in the less GA the
probability of ruptured is more.
Treatment:
The hemodynamic instability is major factor of morbidity
and mortality in ruptured EP cases.
The ectopic pregnancy mortality ratio ranges from 0.48
deaths per 100 000 live births to 0.50 per 100 000 live
births reported from US vital statistics for 2003–2007.25 The
majority cases presents to emergency in hemodynamic shock
which requires emergency laparotomy. The severe anemia
due to hemorrhage is a serious morbid factor.
The incidence of hemoperitonuem was 90.9% (mean volume
619.05 ml) which is more in comparison to the observation
of 86.4% by Rashmi et al and comparable to 93.9% Surya
Chandrika Bondada et al.
In literature 97% of ectopic pregnancies occur in the
Fallopian tubes. The majority occur in the ampullary or
isthmic portions of the Fallopian tubes. About 2-3% occurs
as interstitial ectopic pregnancies (arising in the part of
the tube which goes through the endometrial cavity). The
rare remaining locations include cervical, fimbrial, ovarian
and peritoneal sites, as well as previous caesarean section
scars.26,27 The present study shows similar results.
The intra op laparotomy finding were suggestive of ruptured
tubal ectopic in 90.9% cases while tubal abortion in 2 cases.
The majority of ectopic site was Right side (legend-1)
tubal ectopic (50%) with ampulla in 68.18% time. The
comparison to other studies suggests our study comparable
to these (table-7). In laparotomy the most common
procedure carried out was salpingectomy ± oophorectomy
86.36%, segmentectomy 9.09% and segmentectomy with
recanalization in single case (table-8).
Description of the tissue of ruptured EP28
A) Gross Description:
• Distension of tube with thin or ruptured wall, dusky
red serosa and hematosalpinx, possibly with fetal parts
identified.
B) Microscopic (histologic) description:
• Intraluminal chorionic villi and extravillous trophoblast
(may be degenerated); variable fetal parts
• Decidual change in lamina propria in 1/3; mesothelial
reactive proliferation with papillary formation and
psammoma bodies
In ampullary pregnancy the muscularis is preserved in
52.2%cases which was seen affected in68.18% in present
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Volume 5 | Issue 5 | May 2018 | ICV: 77.83 | ISSN (Online): 2393-915X; (Print): 2454-7379
study.29 In isthmic pregnancy, the trophoblast penetrates
the tubal wall relatively early and therefore patient present
early with symptoms.30 Thus it states that site of ectopic is
also associated with appearance of sign and symptoms.The
ovary is one of the rare site of ectopic and in previous studies
1.07% to 4.40% cases were seen .In our study we too found
single case with rupture ectopic.(legend 2)
CONCLUSION
An ectopic pregnancy can represent in any form within a wide
clinical spectrum, ranging from an asymptomatic patient to
one in shock and in any age group and parity. The high index
of suspicion for history and clinical features and associated
biochemical markers, ultrasonography is sensitive still in non
availability of resources. An open laparotomy and repair of
the affected part is the only treatment in cases of emergency
with blood transfusion. The medical management has no role
in case of ruptured ectopic with shock.
Hazards and human or animal subjects:
We declare that before the study all participants of the study
were informed and after their written consent they were
included in the study. We also declare that there is no hazards
done to any animal and human during the study .The surgical
intervention was the part of the study and was explained to
all participant and written consent was taken. The privacy
policy of the participants has been maintained.
ACKNOWLEDGEMENT
We are greatly thankful to the CMD of our institute Dr.
Vikram I. Shah for encouraging us to conduct research
studies. We thank Medical superintendent Dr.C.Niyogi for
their valuable support and concerns in view of allowing the
data collection, spreadsheet entries and record collection.
We express our gratitude to all the participants in the study
without whom it could not be a successful research. We also
convey our gratitude to the all previous researchers whose
great work is giving us guidance in compiling the present
article.
ABBREVIATIONS
βhCG - Beta Human Chorionic Gonadotropin, d&c -
Dilatation And Curettage, GA - Gestational Age, EP
- Ectopic Pregnancy, IVF - In Vitro Fertilization, LNG
Pill – Levonorgestrel Pill, MA - Medical Abortificient
PID - Pelvic Inflammatory Diseases. TVS - Trans Vaginal
Ultrasonography,
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Source of Support: Nil; Conflict of Interest: None
Submitted: 27-05-2018; Accepted: 29-05-2018; Published: 11-06-2018
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